caries diagnosis · 2021. 2. 17. · • angmar-månsson and ten bosch, 1993 reviewed optical...
TRANSCRIPT
© Dr Julian Holmes 2011
caries diagnosis
research & clinical implications
Masters of Progressive Dentistry
© Dr Julian Holmes 2011
• management of caries
• watch & wait – no longer an option
• failure to diagnose
• prevention & oral hygiene
• drill and fill (amputation)
• pharmaceutical management
research in dental care
© Dr Julian Holmes 2011
research in dental care
which needs to be treated………
© Dr Julian Holmes 2011
research in dental care
which needs to be treated………
© Dr Julian Holmes 2011
• management of caries
• watch & wait – no longer an option
• failure to diagnose
• prevention & oral hygiene
• drill and fill (amputation)
• pharmaceutical management
research in dental care
© Dr Julian Holmes 2011
• dull / ‟etched‟ when dried
• leathery
• sharp probe will „stick‟
• shiny when dried
• hard (remineralised)
• sharp explorer will not „stick‟
caries – clinical signs
active infection or caries inactive / remineralised caries
© Dr Julian Holmes 2011
clinical assessment
evaluate with clinical criteria
• dry tooth / lesion surface
• colour
• white / dark
• appearance
• dull / etched
• shiny
•lesion hardness
• soft / leathery / hard
caries – clinical signs
• pre-ozone
• dull
• leathery
• post-ozone
• shiny
• hard, remineralised
© Dr Julian Holmes 2011
clinical assessment
evaluate with clinical criteria
• dry tooth / lesion surface
• colour – is this a valid criteria?
• white / dark
• appearance
• dull / etched
• shiny
•lesion hardness
• soft / leathery / hard
caries – clinical signs
• pre-ozone
• dull
• leathery
• post-ozone
• shiny
• hard, remineralised
© Dr Julian Holmes 2011
clinical assessment
evaluate with clinical criteria
• dry tooth / lesion surface
• colour
• white / dark
• appearance
• dull / etched
• shiny
•lesion hardness
• soft / leathery / hard
caries – clinical signs
• pre-ozone
• dull
• leathery
• post-ozone
• shiny
• hard, remineralised
© Dr Julian Holmes 2011
• Caries is regularly found beneath a seemingly intact enamel surface
• Frequently the diagnosis of occlusal caries is less than straightforward
• Chan DCN. Current methods and criteria for finding decay in North America. J Dent Ed 57(6):422-425, 1993
research in dental careliterature overview:
© Dr Julian Holmes 2011
• Brostek A
• Early diagnosis and minimally invasive treatment of occlusal caries--a clinical approach. Oral Health Prev Dent. 2004;2 Suppl 1:313-9.
• …diagnostic accuracy is important;
• it determines the quality of the treatment decisions made• the possibility of unnecessary operative intervention
• …there is a decrease in incidence of cavitated caries
• …common presentation of non-cavitated caries
• …accurate diagnosis more difficult.
research in dental careliterature overview:
© Dr Julian Holmes 2011
~ diagnosis & evaluationthe historical face of dentistry
© Dr Julian Holmes 2011
~ diagnosis & evaluationthe historical face of dentistry
© Dr Julian Holmes 2011
present dentistry
a low % of cavities initially present as cavitated
© Dr Julian Holmes 2011
~ diagnosis & evaluation
these tools look for preventative & diagnosis failure
reversible early lesion cannot be found with this technology
the historical face of dentistry
© Dr Julian Holmes 2011
~ diagnosis & evaluationthe historical face of dentistry
© Dr Julian Holmes 2011
~ diagnosis & evaluationthe historical face of dentistry
© Dr Julian Holmes 2011
• The reliability of carious lesion diagnosis by sharp explorer compared to diagnosis of carious lesion by histological cross section was 25%. A seemingly intact occlusal enamel surface may conceal an extensive lesion of the dentin
• Al-Sehaibany, White & Rainey, J Clin Pediatr Dent 20(4):293-298 1996
research in dental careliterature overview:
© Dr Julian Holmes 2011
• Visual Inspection 49%
• Bitewing Rx 55%
• Electrical Conductance Measurement (ECM) 80-90%
• DIAGNOdent 71-94%
Reproducibility (in-vitro and in-vivo studies);
Lussi et al. 1993, 1995, 1999, 2001Attril 2001; Sheehy 2001; Heinrich 2002; Francescut 2003,
literature overview:research in dental care
© Dr Julian Holmes 2011
~ diagnosis & evaluation
present dentistry
© Dr Julian Holmes 2011
~ diagnosis & evaluationthe historical face of dentistry
© Dr Julian Holmes 2011
• Tranaeus S, Shi XQ, Angmar-Mansson B.
• Caries risk assessment: methods available to clinicians for caries detection. Community Dent Oral Epidemiol. 2005 Aug;33(4):265-273.
• …occlusal lesions are initiated on the fissure walls and can therefore be obscured by sound superficial tissue.
• …one effect of regular use of fluorides is greater opacity of enamel, which may obscure underlying lesions in dentin, the so-called 'hidden lesions'.
• …dental radiographs are inadequate for detecting decay in the occlusal surfaces until the lesion is well advanced through the enamel and into the dentin.
• …the clinician relies on visual observation of texture and discoloration, clinical judgment based upon experience, and on tactile sense by probing with an explorer.
research in dental careliterature overview:
© Dr Julian Holmes 2011
Enamel defects
in fissure wall
Decalcified or
hypocalcific
enamel (caries in
this zone is
undetectable by
probe)
De-mineralizing
dentin
modern fissure caries anatomy model
© Dr Julian Holmes 2011
• Tranaeus S, Shi XQ, Angmar-Mansson B.
• Caries risk assessment: methods available to clinicians for caries detection. Community Dent Oral Epidemiol. 2005 Aug;33(4):265-273.
• …occlusal lesions are initiated on the fissure walls and can therefore be obscured by sound superficial tissue.
• …one effect of regular use of fluorides is greater opacity of enamel, which may obscure underlying lesions in dentin, the so-called 'hidden lesions'.
• …dental radiographs are inadequate for detecting decay in the occlusal surfaces until the lesion is well advanced through the enamel and into the dentin.
• …the clinician relies on visual observation of texture and discoloration, clinical judgment based upon experience, and on tactile sense by probing with an explorer.
research in dental careliterature overview:
© Dr Julian Holmes 2011
Not diagnosed by mirror, probe and x-ray examination
Photographs © Dr Graeme Milicich
caries diagnosis
© Dr Julian Holmes 2011
• Tranaeus S, Shi XQ, Angmar-Mansson B.
• Caries risk assessment: methods available to clinicians for caries detection. Community Dent Oral Epidemiol. 2005 Aug;33(4):265-273.
• …occlusal lesions are initiated on the fissure walls and can therefore be obscured by sound superficial tissue.
• …one effect of regular use of fluorides is greater opacity of enamel, which may obscure underlying lesions in dentin, the so-called 'hidden lesions'.
• …dental radiographs are inadequate for detecting decay in the occlusal surfaces until the lesion is well advanced through the enamel and into the dentin.
• …the clinician relies on visual observation of texture and discoloration, clinical judgment based upon experience, and on tactile sense by probing with an explorer.
research in dental careliterature overview:
© Dr Julian Holmes 2011
• The reliability of carious lesion diagnosis by sharp explorer compared to diagnosis of carious lesion by histological cross section was 25%. A seemingly intact occlusal enamel surface may conceal an extensive lesion of the dentin
• Al-Sehaibany, White & Rainey, J Clin Pediatr Dent 20(4):293-298 1996
research in dental careliterature overview:
© Dr Julian Holmes 2011
~ diagnosis & evaluation
present dentistry
these tools look for preventative failure
impossible to „diagnose‟
reversible early lesion cannot be found with this technology
© Dr Julian Holmes 2011
present dentistry~ diagnosis & evaluation
© Dr Julian Holmes 2011
• Caries detector dye
• Digital imaging of radiographs
• Quantitative Light-induced Fluorescence (QLF)
• Laser fluorescence system (DIAGNOdent)
• Optical Caries Monitor (OCM)
• Near-Infra Red Spectroscopy (NIRS)
• Electrical Caries Monitor (ECM)
• Resilience Caries Monitor (RCM)
research in dental careliterature overview:
© Dr Julian Holmes 2011
• Fusayama (1979) reported a typical caries detector consisting of 0.5% basic fuchsin or 1
% acid red solution in propylene glycol.
• Anderson et al, 1985; Kidd et al, 1993) showed that caries dyes does not necessarily
discriminate infected or sound tissues.
• Kidd et al, 1993 showed the use of dye may lead to over preparation of cavities at the
enamel-dentine junction.
• Yip et al, 1994 showed dyes tend to result in the removal of sclerotic (translucent) and
reparative dentine over the pulpal surface.
research in dental careliterature overview:
• Caries detector dye
• Digital imaging of radiographs
• Quantitative Light-induced Fluorescence
(QLF)
• Laser fluorescence system (DIAGNOdent)
• Optical Caries Monitor (OCM)
• Near-Infra Red Spectroscopy (NIRS)
• Electrical Caries Monitor (ECM)
• Resilience Caries Monitor (RCM)
© Dr Julian Holmes 2011
• Wenzel and Fejerskov reported on the potential advantages of image enhancement in
1992.
• A total of 124 third molars were radiographed in-vivo and then "captured" digitally using
a charge coupled device (CCD) video camera.
• The in-vitro histological appearances of these teeth were used as a "gold standard".
• The sensitivity and specificity of dentinal caries detection for the conventional
radiographs were 0.48 and 0.81, respectively.
• When these radiographs were digitally enhanced, the sensitivity and specificity became
0.71 and 0.85 respectively.
research in dental careliterature overview:
• Caries detector dye
• Digital imaging of radiographs
• Quantitative Light-induced Fluorescence
(QLF)
• Laser fluorescence system (DIAGNOdent)
• Optical Caries Monitor (OCM)
• Near-Infra Red Spectroscopy (NIRS)
• Electrical Caries Monitor (ECM)
• Resilience Caries Monitor (RCM)
© Dr Julian Holmes 2011
• Sundström et al, 1985 Teeth illuminated with a blue-violet light will emit green/yellow
light wit a wavelength of 488 nm, the wavelength most suitable for detection of initial
carious lesions.
• Angmar-Månsson and ten Bosch, 1993 reviewed optical methods for the quantification of
enamel caries.
research in dental careliterature overview:
• Caries detector dye
• Digital imaging of radiographs
• Quantitative Light-induced Fluorescence
(QLF)
• Laser fluorescence system (DIAGNOdent)
• Optical Caries Monitor (OCM)
• Near-Infra Red Spectroscopy (NIRS)
• Electrical Caries Monitor (ECM)
• Resilience Caries Monitor (RCM)
© Dr Julian Holmes 2011
• Lussi et al., 1999 - reported on a laser-based device (DIAGNOdent, KaVo, Biberach,
Germany) for detection of occlusal caries in-vitro and in-vivo.
• Shi et al., 2000 - diagnostic accuracy of DIAGNOdent to detect occlusal caries was
significantly better than that of radiography (p < 0.001) under in-vitro conditions.
• Shi et al., 2001- validation studies and studies on repeatability and reproducibility must
be performed in-vivo before large scale application of this device.
• Lussi et al., 2001 - reported a validation and comparison study on QLF and
DIAGNOdent for the quantification of smooth surface caries. The correlation with the
lesion depth was similar for the two methods tested (r = 0.85).
research in dental careliterature overview:
• Caries detector dye
• Digital imaging of radiographs
• Quantitative Light-induced Fluorescence
(QLF)
• Laser fluorescence system (DIAGNOdent)
• Optical Caries Monitor (OCM)
• Near-Infra Red Spectroscopy (NIRS)
• Electrical Caries Monitor (ECM)
• Resilience Caries Monitor (RCM)
© Dr Julian Holmes 2011
• measures volume-reflection of teeth in-vivo and in-vitro at two wavelengths at the same
time under daylight conditions.
• Brinkman et al, 1988 studied the OCM to quantify incipient smooth surface carious
lesions in-vivo. The system was validated against natural lesions in extracted teeth, and
the depth of these lesions and their mineral loss were measured by microradiography.
• The correlation coefficient between these two parameters was 0.96 and the correlation
between optical measurement and lesion depth 0.71.
research in dental careliterature overview:
• Caries detector dye
• Digital imaging of radiographs
• Quantitative Light-induced Fluorescence
(QLF)
• Laser fluorescence system (DIAGNOdent)
• Optical Caries Monitor (OCM)
• Near-Infra Red Spectroscopy (NIRS)
• Electrical Caries Monitor (ECM)
• Resilience Caries Monitor (RCM)
© Dr Julian Holmes 2011
• Borsboom and ten Bosch, 1983; ten Bosch et al, 1985; Mardones et al, 1999. the
application of Near Infra Red Spectroscopy (NIRS) is relatively new in the field of
dentistry. Optical scattering can be used to quantify the degree of demineralisation in
enamel and dentine.
• The degree of reflection of a tooth is determined by its local scattering, absorption and
fluorescent properties.
• In a sound tooth, scattering is more prominent than absorption. Both scattering and
absorption frequently occur along the light path in dentine but this is not seen in enamel.
• Mardones 2000 showed that NIRS was able to detect changes in water content of
demineralised enamel and dentine tissues.
research in dental careliterature overview:
• Caries detector dye
• Digital imaging of radiographs
• Quantitative Light-induced Fluorescence
(QLF)
• Laser fluorescence system (DIAGNOdent)
• Optical Caries Monitor (OCM)
• Near-Infra Red Spectroscopy (NIRS)
• Electrical Caries Monitor (ECM)
• Resilience Caries Monitor (RCM)
© Dr Julian Holmes 2011
• Pincus in 1951. described electrical conductance measurements in caries detection.
• Borsboom in 1997 developed ECM III (Lode Diagnostics BV, Holland). It measures the electrical
resistance of each carious lesion.
• The principle was described by White et al, 1978. Sound tooth tissue is a good insulator whereas
demineralised tooth tissue is a poor insulator as it contains large quantities of water. Hence, high
resistance measurements indicate well-mineralised tissue, whilst low resistance values are associated
with demineralised tissue.
• Flaitz et al, 1986, Gente & Wenz, 1991 demonstrated that there is a correlation between electrical
resistance and dentine thickness above the pulp; there is a strong correlation between lesion depth in
pits and electrical resistance of the lesions.
• In-vivo studies include White et al, 1981; Rock and Kidd, 1988; Verdonschot et al, 1992; Lussi et al,
1995; Ashley et al, 2000.
research in dental careliterature overview:
• Caries detector dye
• Digital imaging of radiographs
• Quantitative Light-induced Fluorescence
(QLF)
• Laser fluorescence system (DIAGNOdent)
• Optical Caries Monitor (OCM)
• Near-Infra Red Spectroscopy (NIRS)
• Electrical Caries Monitor (ECM)
• Resilience Caries Monitor (RCM)
© Dr Julian Holmes 2011
ECM
• measures porosity
~ clinical & lesion extent assessment
caries diagnosis
© Dr Julian Holmes 2011
~ clinical & lesion extent assessment
ECM
• measures porosity
• caries extent / severity
caries diagnosis
© Dr Julian Holmes 2011
• The RCM was developed as a diagnostic device to measure the resilience of the surface
layer of dentine providing a quantitative index of the surface texture (Prinz et al, 1998).
• The RCM data, so far exhibited, is shown to present two extreme conditions for root
dentine: (1) demineralised with remaining collagen and (2) sound/high mineral surface
layer or sound tissue. This RCM scale with the two extremes may be used for further
experiments to monitor artificial and natural conditions in the mouth.
• Broman (1999) demonstrated that the RCM was capable of detecting changes in dentine
after a 10 min immersion in 0.1 mM acetic acid, whereas tactile evaluation using a
conventional explorer was unable to detect these changes until a period of three weeks had
elapsed. These data indicate that the RCM is more sensitive than a visual-tactile method
(Prinz et al, 1999).
research in dental careliterature overview:
• Caries detector dye
• Digital imaging of radiographs
• Quantitative Light-induced Fluorescence
(QLF)
• Laser fluorescence system (DIAGNOdent)
• Optical Caries Monitor (OCM)
• Near-Infra Red Spectroscopy (NIRS)
• Electrical Caries Monitor (ECM)
• Resilience Caries Monitor (RCM)
© Dr Julian Holmes 2011
• González-Cabezas et al, (2001) demonstrated that the Electrical Caries Monitor
(ECM) had a higher specificity than the QLF and laser fluorescence system
(DIAGNOdent) for the detection of root caries in-vitro.
• DIAGNOdent showed higher sensitivity when compared to these detection
systems. These authors concluded that QLF, ECM, DIAGNOdent with visual
examination were equally accurate in detecting caries.
research in dental careliterature overview: conclusions
• Caries detector dye
• Digital imaging of radiographs
• Quantitative Light-induced Fluorescence
(QLF)
• Laser fluorescence system (DIAGNOdent)
• Optical Caries Monitor (OCM)
• Near-Infra Red Spectroscopy (NIRS)
• Electrical Caries Monitor (ECM)
• Resilience Caries Monitor (RCM)
© Dr Julian Holmes 2011
• Visual Inspection 49%
• Bitewing Rx 55%
• ElectricalConductanceMeasurement 80-90%
• DIAGNOdent 71-94%
Reproducibility (in-vitro and in-vivo studies)
• Attril 2001; Sheehy 2001; Heinrich 2002; Francescut 2003,
• Lussi et al, 1993, 1995, 1999, 2001.
research in dental careliterature overview:
© Dr Julian Holmes 2011
• What works, is easy to use, and has a low learning curve?
• Laser Flourescence – DIAGNOdent, KaVo
research in dental careliterature overview: conclusions
• Caries detector dye
• Digital imaging of radiographs
• Quantitative Light-induced Fluorescence
(QLF)
• Laser fluorescence system (DIAGNOdent)
• Optical Caries Monitor (OCM)
• Near-Infra Red Spectroscopy (NIRS)
• Electrical Caries Monitor (ECM)
• Resilience Caries Monitor (RCM)
© Dr Julian Holmes 2011
KaVo DIAGNOdent
caries diagnosis
• measures fluorescence
• high correlation with the
ECM (Lode, Holland)
• validated index
Lussi A, Switzerland
© Dr Julian Holmes 2011
caries diagnosis• new generation of DIAGNOdent
• occlusal caries detection
• inter-proximal detection
• integrated design
• wire-free
• rechargeable unit
BUT !• no patient inter-action
• ability to „teach‟ lost
• takes more time to
„map‟
• current research
• no in-vivo studies
• values not comparable
• no validated index
Krause F, Jepsen S, Braun A.
Comparison of two laser
fluorescence devices for the
detection of occlusal caries in vivo.
Eur J Oral Sci 2007; 115: 252–256
study.
© Dr Julian Holmes 2011
what about ?~ diagnosis & evaluation; research results
Lussi A, Caries Research, 1999; 33, 297
DIAGNOdent values No action Prevention Record and monitor Sealant Drilling and filling
0-5
5-10
10-15
15-20
20-25
30+
caries diagnosis
© Dr Julian Holmes 2011
~ diagnosis & evaluation; research results
Holmes J & Lynch E, 2001 (from Lussi A, Caries Research, 1999; 33, 297)
3+ mm into dentine CSI 5> 30Visible on X-rays -> DV
1-2mm into dentine CSI 425~29? visible on X-rays -> DV
at the edj CSI 320~24stain -> DV
confined to enamel CSI 210~19white spot -> DV
extent of carious lesionDIAGNOdent Values
a basic guide to the DIAGNOdent values & The CSI
caries diagnosis
© Dr Julian Holmes 2011
© J
ulia
n H
olm
es 2
007
caries diagnosis
© Dr Julian Holmes 2011
#16
#46
#26
#36
Diagnodent Record at Start
caries diagnosis
© Dr Julian Holmes 2011
Decalcified or
hypocalcific
enamel
Organic plug
Acid percolation
through porous,
hypocalcific
enamel can lead to
failure of the
organic plug
modern fissure caries model
© Dr Julian Holmes 2011
Continuing
decalcification
+dentin caries
Presentation is
inverted
compared to the
traditional
model
modern fissure caries model
© Dr Julian Holmes 2011
Organic plug
(This area may
not be
decalcified
thus a probe
won‟t stick)
Enamel defects
in fissure wall
Decalcified or
hypocalcific
enamel (caries in
this zone is
undetectable by
probe)
De-mineralizing
dentin
modern fissure caries anatomy model(summary of realistic „coke bottle „ shape)
© Dr Julian Holmes 2011
the DIAGNOdent can diagnose this zone in the fissure
© Dr Julian Holmes 2011
As the lesion progresses, the
demineralization in the
enamel fissure walls
becomes more severe
This gives a higher reading,
but this is still not totally
predictive of the depth of the
dentin caries
DIAGNOdent readings
© Dr Julian Holmes 2011
DIAGNOdent readings
Dentin caries developing
under enamel defects in the
depths of the fissure will
give lower readings because
of the thickness of the
overlying sound enamel
This is a form of “hidden
caries”
© Dr Julian Holmes 2011
If a reading is obtained that
causes concern, yet there is
no visible evidence to
support the reading,
minimally invasive
techniques are essential
when investigating the
fissure
step down technique
© Dr Julian Holmes 2011
Carefully open the fissure
entrance with air-abrasion
step down technique
© Dr Julian Holmes 2011
Re scan the fissure. If the
reading drops, the enamel
damage was present in the
fissure opening. If the
reading remains constant, or
increases, there is caries
deeper in the fissure
complex.
step down technique
© Dr Julian Holmes 2011
Sudden increase in reading while rotating
the tip in a fissure
If there is fissure caries
developing in one wall of a
fissure, the initial angulation
of the beam may completely
miss the lesion. As an
example, the reading at this
point the reading may only
be 5-10
© Dr Julian Holmes 2011
As the beam approaches the
carious wall, the reading
will begin to increase
Sudden increase in reading while rotating
the tip in a fissure
© Dr Julian Holmes 2011
Once the beam is directed at
the lesion, there will be a
rapid increase in the
reading. The reading could
now be 30-40, yet there is
no external evidence of a
lesion.
Sudden increase in reading while rotating
the tip in a fissure
© Dr Julian Holmes 2011
Many of these lesions are
very localized and subtle
and if the fissure is not
entered with minimally
invasive techniques like Air-
abrasion, they will not be
observed and the reading
from the DIAGNOdent is
consequently discredited.
Sudden increase in reading while rotating
the tip in a fissure
© Dr Julian Holmes 2011
Sudden increase in reading while rotating
the tip in a fissure
Readings that oscillate with
simple rotation of the tip are
generally very reliable. If
there was something present
in the fissure entrance to
cause a false positive, the
reading would remain
constantly high, rather than
oscillate with the rotation of
the tip
© Dr Julian Holmes 2011
© Dr Julian Holmes 2011
• management of caries
• watch & wait – no longer an option
• failure to diagnose
• prevention & oral hygiene
• drill and fill (amputation)
• pharmaceutical management
research in dental care
© Dr Julian Holmes 2011
what do we know about caries?• sugar alone does not cause decay
• teeth must be present
• bacteria must be present
theories of decay
• debris and plaque is where decay starts
• lesions tend to develop over long time periods; up to several years
• over 450 species of bacteria can be found in the mature lesion
• complex interactions between plaque, bacterial colonies & host
• inoculation / immunisations for caries ?
- “multifactorial” -
the historical face of dentistry
© Dr Julian Holmes 2011
decay – the chemistry of caries
– bacteria are present in the oral environment, and cover all surfaces of teeth
– there is a balance of mineral loss, and mineral uptake by the tooth surface
– the balance is altered by
– the buffering capacity of saliva
– the pH of the saliva, food, drinks
– the pH of the „normal‟ bacterial community
– the oral hygiene status
– systemic illnesses
– physical characteristics – crowded teeth, decreased ability to
maintain hygiene
– patient‟s choice – avoidance of fluoride tooth pastes.
the historical face of dentistrytheories of decay
© Dr Julian Holmes 2011
decay – the chemistry of caries
– where the balance shifts towards acidic pH and debris collection
– these bacteria form a niche environment that leads to
predominantly acid forming bacteria
– this causes demineralisation of the surrounding enamel, and
dentine, leading to a cavity
– the cavity forms a protected environment for this bacterial colony
– oral hygiene, high-dose fluoride, chlorhexidine, chlorates, do not
RELIABLY prevent or reverse caries
– review in Holmes J Gerodontology 2003;Vol 20, No2, 106-114
the historical face of dentistrytheories of decay
© Dr Julian Holmes 2011
~ prevention & oral hygienethe historical face of dentistry
© Dr Julian Holmes 2011
theories of decay
the bad news for our patients!– recent research suggests fluoride delays the onset of
decay to late teens
– dentists are masters of the process of amputation of the
diseased tissue
– chemo-mechanical (Carisolv), air abrasion, diamond and metal
burs, lasers to dismantle teeth
– and then dentists place a filling that may need to be
replaced in 12-18 months
the historical face of dentistry
© Dr Julian Holmes 2011
theories of decay
the good news for our patients!
– we do know that tooth tissue can remineralise in the right
environment, BUT it is unpredictable
– there are no studies that show remineralised areas of tooth
tissue subsequently being involved in further decay
– possible to prevent caries
the historical face of dentistry
© Dr Julian Holmes 2011
• prevention or improved oral hygiene alone will not arrest or
reverse caries predictably
• Nyvad B, Fejerskov O. Active root surface caries
converted into inactive caries as a response to oral
hygiene. Scand J Dent Res 1986; 94: 281-284
• Papas A, Russell D, Singh M et al. Double blind clinical
trial of a remineralizing dentifrice in the prevention of
caries in a radiation therapy population. Gerodontology
1999; 16: 2-10
research in dental careliterature overview:
© Dr Julian Holmes 2011
~ concepts of sealantsthe historical face of dentistry
© Dr Julian Holmes 2011
~ concepts of sealantsthe historical face of dentistry
© Dr Julian Holmes 2011
• management of caries
• watch & wait – no longer an option
• failure to diagnose
• prevention & oral hygiene
• drill and fill (amputation)
• pharmaceutical management
research in dental care
© Dr Julian Holmes 2011
• management of caries
• watch & wait – no longer an option
• failure to diagnose
• prevention & oral hygiene
• drill and fill (amputation)
• pharmaceutical management
research in dental care
© Dr Julian Holmes 2011
• the key to predictability is the elimination of the acid niche
environment; bacteria and their bio-molecules
• Lynch E, Silwood CJL, Smith C, Grootveld M.
Oxidising actions of an Anti-Bacterial Ozone-
Generating Device towards Root Caries Biomolecules.
IADR Abstract 2002.
• Lynch E , Silwood CJ, Abu-Naba'A L, Al Shorman H,
Baysan A, Holmes J and Grootveld M. Oxidative
Consumption of Root Caries Biomolecules using
Ozone. IADR Abstract 2003.
research in dental careliterature overview:
© Dr Julian Holmes 2011
• management of caries
• watch & wait – no longer an option
• failure to diagnose
• prevention & oral hygiene
• drill and fill (amputation)
• pharmaceutical management
research in dental care
© Dr Julian Holmes 2011
if you are going to
watch something
you have to be very sure of what
you are watching